Comprehensive Textbook of AIDS Psychiatry

The Comprehensive Textbook of AIDS Psychiatry will serve as a standard reference for psychiatrists and other mental health professionals providing care for HIV-positive individuals. This is a scholarly work informed by the experience of many pioneers in AIDS care and research, including Dr. Mary Ann Cohen, who first wrote about psychiatric care of people with AIDS when it was a deadly new epidemic without medical treatment. She and her colleagues return to chronicle the vast range of knowledge that has been gained through nearly three decades of research and experience in caring for people with AIDS.

The scope of this text ranges from initial biopsychosocial assessment to end-of-life care. The reviews are all extensively researched, and the information is useful for both general practice and HIV specialty care. The clinician will learn to recognize HIV-related cognitive, motor, and psychiatric manifestations of HIV infection, reconsider the treatment of psychiatric disorders of patients who are infected with HIV, identify psychotherapeutic modalities appropriate for persons at various stages of HIV disease, and understand the particular concerns about medication adherence, provider “burnout,” and ethical dilemmas in the treatment of HIV-infected individuals. The chapter on substance use disorders emphasizes the role of specific substances in HIV transmission and high-risk behaviors, and the review of hepatitis C is essential knowledge for treating the nearly 30% of HIV-positive patients who are co-infected. For those interested in more specific comorbidities, there are chapters on HIV-associated renal disease and endocrinopathies, antiretroviral-related metabolic side effects, including lipodystrophies and cardiovascular disease, opportunistic infections associated with AIDS, and two excellent chapters on the neuropathological manifestations of HIV infection. The chapter by editor Jack Gorman and colleagues summarizes advances in psychoneuroimmunology.

The drug-drug interactions between antiretroviral and psychotropic medications, such as the impact of ritonavir on levels of psychiatric medications through cytochrome P450 enzyme inhibition or the withdrawal symptoms that can be caused by enzyme induction when nevirapine is administered in conjunction with methadone, are thoroughly reviewed. There are also multiple reference tables summarizing these interactions, although these should be used cautiously and with the understanding that clinical effects can vary significantly between individuals. There is also a brief review of the mechanisms of action of antiretroviral medications, such as interference with viral transcription and replication, which includes protease inhibitors, reverse transcriptase inhibitors, and the newer fusion and integrase inhibitors. However, decisions about specific antiretroviral combination therapies by likely viral resistance based on genotype mutations are beyond the scope of this book.

This text establishes a standard of excellence for the care of the individual HIV-positive patient by the individual psychiatrist within the context of the biopsychosocial model. There are also chapters on HIV and youth, serodiscordant couples, and the elderly from a developmental life cycle perspective. However, there is little analysis from a population perspective, such as the myriad issues faced by the population of HIV-positive women of reproductive age. The notable exceptions are a chapter on the homeless HIV-positive population and a provocative chapter suggesting that the disruption of already disadvantaged communities through the "engine" of incarceration in the nation"s prisons accounts for the disproportionate impact of HIV on racial and ethnic minorities. There are estimates that one in five HIV-positive individuals in this country passes through the correctional system, and the chapter proposes system interventions targeting this population. Disparities of care and problems in the health care system are discussed in a chapter on health services that includes an interesting historical perspective on syringe exchange programs as a community intervention.

Finally, while there is a rich discussion of the role of psychiatric disorders in HIV transmission and high-risk behaviors in this book, there is little discussion of the role of the psychiatrist in HIV prevention. HIV psychiatry is a prime example of the need for a public mental health perspective that addresses populations as well as individual patients, explores sociocultural roots of illness as well as the medical and psychological, and targets interventions for communities as well as for individuals. Psychiatrists should be engaged in disease prevention as well as diagnosis and treatment.